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Other oral mucosal pustular conditions to rule out include parulis related to an abscess of odontogenic origin, subcorneal pustular mucositis, pyostomatitis vegetans, and herpetiform stomatitis.5 Angular cheilitis, enlarged fungiform papilla, gingivitis, and periodontitis are also associated with psoriasis. In fact, focal changes in the gingival mucosa and breakdown of proximal periodontal tissues associated with flares of cutaneous disease “suggest a potential role for gingival psoriasis in the pathogenesis of the periodontal disease.”1 In one study, salivary expression of proinflammatory cytokines (eg, TNV-a, TGF-b1, MCP-1, and IL-1b) was significantly higher in psoriatic patients than in controls, suggesting a common inflammatory process.6 Assessing specific inflammatory markers may be relevant for evaluating the extent of oral disease.1
The diagnostic workup should include a detailed history regarding pre-existing and/or current cutaneous psoriasis, family history of the disease, clinical and histological evidence, HLA typing when indicated, and the exclusion of other potential causes for oral findings.1 This is “particularly relevant when the recent onset of oral signs and symptoms could mask a potential association between the long-standing or distant cutaneous psoriasis and its oral counterpart.”1
A summary of the evaluation can be found in Table 2.
Treatment
Management of oral psoriasis is “not well described,” according to the authors, because—unlike cutaneous psoriasis—most cases are asymptomatic, transient, and do not need specific interventions. Moreover, when cutaneous disease is controlled, symptomatic oral psoriasis is likewise controlled.
Many of the therapeutic strategies that are used in cutaneous psoriasis are not appropriate for use in the oral cavity.1 Topical or intralesional steroids, guided by symptom severity and location, are generally efficacious.1 However, since oral psoriasis may resemble or be comorbid with oral candidiasis, caution should be used when considering corticosteroid treatment.1
Several medications that are used to treat cutaneous psoriasis, while efficacious, may lead to adverse effects when used in the oral cavity. For example, retinoids may be associated with xerostomia, cyclosporine with gingival enlargement, and methotrexate with stomatitis.1
Recommended treatment approaches are found in Table 3.
Nonpharmacologic Interventions
Because patients with psoriatic arthritis or severe cutaneous involvement may have difficult holding a toothbrush or performing adequate oral hygiene, the authors recommend regular oral evaluations to prevent, detect, and manage oral disease. Regular evaluation can also assess potential adverse effects of antipsoriatic medications in the oral cavity.1 The authors emphasize that patient education is an essential aspect of management. (Table 4)
Conclusion
The authors conclude by noting that, although oral psoriasis is often asymptomatic, it can cause “discomfort and concern” for the patient. Therefore, “clinicians should be familiar with the spectrum of oral signs and symptoms, diagnostic workup, and management strategies for symptomatic oral psoriasis.”
References
1. Fatahzadeh M, Schwartz RA. Oral psoriasis: an overlooked enigma. Dermatology. 2016;232(3):319-25.
2. Daneshpazhooh M, Moslehi H, Akhyani M, Etesami M. Tongue lesions in psoriasis: a controlled study. BMC Dermatol. 2004 Nov 4;4(1):16.
3. Bruce AJ, Rogers RS 3rd. Oral psoriasis. Dermatol Clin. 2003 Jan;21(1):99-104.
4. Rahman MA, Fikree M. Perioral psoriasis. J Eur Acad Dermatol Venereol. 2000 Nov;14(6):521-2.
5. Tarakji B, Umair A, Babaker Z, et al. Relation between psoriasis and geographic tongue. J Clin Diagn Res. 2014 Nov;8(11):ZE06-7.
6. Ganzetti G, Campanati A, Santarelli A, et al. Involvement of the oral cavity in psoriasis: results of a clinical study. Br J Dermatol. 2015 Jan;172(1):282-5.
